Quality Improvement: Launching Conscious Sedation Hysteroscopy in a District Hospital

Authors: Dr Prashida Guha Sarkar, Ms Rumana Rahman, Bedford Hospital

Objectives: RCOG recommends provision of outpatient hysteroscopy services to investigate and treat women with abnormal uterine bleeding. We have highlighted the key elements that were instrumental in formulating a standard operating procedure and introducing a new service in a district hospital.

Design: This was a quality improvement project to introduce hysteroscopy under conscious sedation services at Bedford hospital. The primary objective was to offer hysteroscopy with robust analgesia, whilst avoiding the risks of general anaesthesia, to alleviate the anxiety amongst patients involving pain and discomfort associated with hysteroscopy. The secondary objective was to lower the burden of hysteroscopy workload on day-case theatre sessions.

Method: We conducted an audit in March 2024 to investigate failed attempts at outpatient hysteroscopy, leading to women opting for hysteroscopy under general anaesthesia. Pain and discomfort during procedure were the main causes for this. To address this and provide a suitable alternative painless option, we proposed an action plan to implement vaginoscopy wherever appropriate in outpatient setting and to create a service for hysteroscopy under conscious sedation. A proposal with the details of the service including the resources required and strict set of indications and contraindications was formulated and presented to the administrative and clinical governance team at Bedford hospital. A cost-benefit estimate showed that this service had potential to be cost-effective as well as time-efficient, in addition to providing a safe, painless option for hysteroscopy for patients. Following the approval of this proposal, pilot sessions for hysteroscopy under conscious sedation were introduced at Bedford hospital.

Results: Since September 2024, Bedford Hospital has provided weekly hysteroscopy sessions under conscious sedation with the support of the anaesthetic, gynaecology and theatre teams. Initial patient feedback has been largely positive. A prospective patient satisfaction survey is being undertaken to record formal feedback and identify areas for improvement.

Conclusion: All women should receive appropriate counselling about the procedure, including alternative analgesic options and modes of anaesthesia. Pain and anxiety can  negatively impact patient satisfaction, safety and effectiveness of outpatient hysteroscopy, and conscious sedation, wherever feasible, should be offered as an alternative option. With careful planning, we were able to successfully introduce hysteroscopy under conscious sedation as a safe, cost-effective and sustainable service.